Request for Confidential Communications This form will allow me, As a CIGNA HealthCare* Member Parti 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your personal information in the 'VERIFICATION' section. Include your name, date of birth, and contact number. Ensure all applicable fields are completed for verification purposes.
3. In the 'REQUEST' section, specify how you wish to receive communications regarding your PHI. If you prefer an alternate means or location, provide the necessary details and explain why this is required.
4. If applicable, indicate any restrictions on access to your PHI by checking the appropriate box. Remember that if you are not the Subscriber, this may limit your access to information online.
5. Complete the 'VERIFICATION QUESTIONS' if you checked the restriction request. Provide answers that are easy for you to remember but do not share them with others.
6. Sign and date the form in the 'SIGNATURE AND NOTARIZATION' section. Ensure that a notary public witnesses your signature for validation.

Start using our platform today to easily complete and submit your Request for Confidential Communications form!